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Gepubliceerd in: Netherlands Heart Journal 9/2021

Open Access 31-07-2020 | Rhythm Puzzle – Answer

A young man with out-of-hospital cardiac arrest—it goes round and round

Auteurs: S. C. M. D. Panman, J. M. ter Maaten, Y. Blaauw

Gepubliceerd in: Netherlands Heart Journal | Uitgave 9/2021

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Answer

The electrocardiogram (ECG) at presentation at the emergency department showed a sinus rhythm of 98 beats per minute with a delta wave. ECG findings are suggestive of pre-excitation with an accessory pathway between the atria and ventricle, as has been described by Wolff, Parkinson and White. Using the Arruda algorithm, the localisation of the accessory pathway is most likely left posterior [1].
The ECG during palpitations at the cardiac care unit showed an atrioventricular reciprocating tachycardia (AVRT), a macroreentrant tachycardia over an accessory pathway, the most common type of arrhythmia associated with the Wolff-Parkinson-White syndrome [2]. An AVRT can start after an extra atrial or ventricular beat over the slow pathway when the fast pathway is still refractory, with retrograde conduction over the accessory pathway. Treatment of choice is a sodium channel blocker that blocks conduction across and prolongs the refractoriness of the accessory pathway, allowing the fast pathway to take over [3].
During the first 12 h after admission our patient had recurrent AVRT episodes. We treated him with flecainide after which the AVRT episodes ended almost every time. One time it changed into atrial fibrillation with antidromic conduction over the accessory pathway, also known as FBI—fast, broad and irregular—(Fig. 1), requiring acute cardioversion. Given the delta wave on the ECG, the high recurrence rate of supraventricular tachycardia episodes, and the out-of-hospital cardiac arrest, the day after admission an electrophysiology study (EPS) was performed. Indeed, a left posterior accessory pathway was identified and successfully ablated. Fig. 2 shows the ECG after pathway ablation, where no delta wave was visible any longer. Therefore, when there is a high clinical suspicion of a Wolff-Parkinson-White syndrome, EPS should be considered.

Conflict of interest

S.C.M.D. Panman, J.M. ter Maaten and Y. Blaauw declare that they have no competing interests.
Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://​creativecommons.​org/​licenses/​by/​4.​0/​.
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Literatuur
1.
go back to reference Arruda MS, McClelland JH, Wang X, et al. Development and validation of an ECG algorithm for identifying accessory pathway ablation site in Wolff-Parkinson-White syndrome. J Cardiovasc Electrophysiol. 1998;9:2–12. CrossRef Arruda MS, McClelland JH, Wang X, et al. Development and validation of an ECG algorithm for identifying accessory pathway ablation site in Wolff-Parkinson-White syndrome. J Cardiovasc Electrophysiol. 1998;9:2–12. CrossRef
2.
go back to reference Jabbour F, Grossman SA. Atrioventricular reciprocating tachycardia/atrioventricular reentrant tachycardia (AVRT). Treasure Island (FL): StatPearls; 2019. Jabbour F, Grossman SA. Atrioventricular reciprocating tachycardia/atrioventricular reentrant tachycardia (AVRT). Treasure Island (FL): StatPearls; 2019.
3.
go back to reference Crozier I. Flecainide in the Wolff-Parkinson-White syndrome. Am J Cardiol. 1992;70:26A–32A. CrossRef Crozier I. Flecainide in the Wolff-Parkinson-White syndrome. Am J Cardiol. 1992;70:26A–32A. CrossRef
Metagegevens
Titel
A young man with out-of-hospital cardiac arrest—it goes round and round
Auteurs
S. C. M. D. Panman
J. M. ter Maaten
Y. Blaauw
Publicatiedatum
31-07-2020
Uitgeverij
Bohn Stafleu van Loghum
Gepubliceerd in
Netherlands Heart Journal / Uitgave 9/2021
Print ISSN: 1568-5888
Elektronisch ISSN: 1876-6250
DOI
https://doi.org/10.1007/s12471-020-01481-3

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